Provider Demographics
NPI:1023000791
Name:LYNE, JEFFREY R (DC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
Last Name:LYNE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1633 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-1839
Mailing Address - Country:US
Mailing Address - Phone:608-837-7712
Mailing Address - Fax:608-825-6638
Practice Address - Street 1:1633 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-1839
Practice Address - Country:US
Practice Address - Phone:608-837-7712
Practice Address - Fax:608-825-6638
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2193111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38797600Medicaid
WI38797600Medicaid
WIT62653Medicare UPIN